Healthcare Provider Details

I. General information

NPI: 1063671600
Provider Name (Legal Business Name): DEEPA BANGALORE GOTUR MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: PRAKASH DEEPA BANGALORE SURYA MD

II. Dates (important events)

Enumeration Date: 06/09/2008
Last Update Date: 09/01/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6565 FANNIN ST F270
HOUSTON TX
77030-2703
US

IV. Provider business mailing address

6565 FANNIN ST F270
HOUSTON TX
77030-2703
US

V. Phone/Fax

Practice location:
  • Phone: 713-441-3020
  • Fax:
Mailing address:
  • Phone: 713-441-3020
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number242789
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License NumberN0628
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: